The proposed research focuses on the adequacy of community care plans for Medicare beneficiaries discharged from acute to home care. The unit for analyzing adequacy is the individualized care plan, conceptualized as the patient's total set of formal and informal services. Objectives are to (1) test measures of care plan adequacy; (2) test the impact on care plan adequacy of withdrawal of Medicare reimbursement for home health services; (3) test the relationship between care plan adequacy and patient function during the period of post-hospital recovery; (4) test the relationship between care plan adequacy and traditional dispositional criteria, such as readmission; and (5) identify factors associated with adequate care plans. The prospective study will follow chronically ill, elderly Medicare patients during the period immediately following hospital discharge through their use of 14 weeks of home care. A sample of 200 patients, hospitalized for congestive heart failure, will be observed at discharge and at 2, 6, 10, and 14 weeks following discharge. Major dependent variables include care plan adequacy, level of patient function, and disposition, defined in terms of continual community stay, readmission, institutionalization, and mortality. Independent variables include patient demographic, social support, medical, and service factors. Data will be obtained from professionals, medical records, and patients. Care plan adequacy will be evaluated using patient and professional assessments (hospital and in-home), and using likert-type and ratio (needs met to total needs) scores. Methods of data analysis include repeated measures analysis of variance, generalized least squares procedures on pooled data, and life events analysis. Results will be beneficial methodologically and substantively, yielding advances in measuring care plan outcomes and understanding the impact of withdrawal of Medicare-funded home care services.